Cityview Nursing and Rehabilitation Center

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food items were kept away from potential airborne contaminants (dust and fuzz) on the ceiling vents. This failure could place residents at risk for food contamination and food-borne illness. Findings included: Observation on 07/23/24 at 8:55 AM revealed a total of ten air conditioning vents in the kitchen area were observed to have built-up fuzz and dust stuck to them. Interview on 07/24/24 at 11:55 AM with Dietary Aide revealed all kitchen staff were responsible for cleaning kitchen equipment. She stated all kitchen staff had daily assignments. Dietary Aide stated maintenance staff were responsible for cleaning the air vents. She stated she could not recall when was the last time air vents were cleaned. She stated the air vents needed to be clean because of all the build-up. She stated kitchen staff would report to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to provide a private meeting space for the residents' monthly group meetings for 10 of 10 confidential residents reviewed for resident council. The facility failed to provide a private space for resident group meetings. This failure could place residents, who attended resident group meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Interview on 07/23/24 at 9:21 AM with the Activity Director revealed the resident group meetings were being held up stairs in the open middle area. Activity Director stated the only other space would be the conference room which was where the survey team was working. Observation and interview on 07/24/24 beginning at 10:30 AM, during a confidential resident group meeting with 10 residents, revealed the meeting was held in the activity/dining room. There were doors that closed off the space from one hall to another hall; however, in between the hall there was several offices to include the DON's office, the Social Worker's office, the HR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 4 of 6 residents (Residents #334, #386, #88 and #109) reviewed for ADLs. 1.The facility failed to ensure Resident #334 received showers as scheduled. 2. The facility failed to ensure Resident #386 received showers as scheduled. 3. The facility failed to provide Resident #88 assistance with daily oral care. 4. The facility failed to provide Resident #109 assistance with daily oral care. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem. The findings include: 1.Review of Resident #334's face sheet, dated 07/25/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Review of Resident #334's admission MDS Assessment, dated 07/19/24, reflected a BIMS score of 14,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 (Resident #32 and Resident #88) of 6 residents reviewed for respiratory care, in that: The facility failed to obtain physician orders for Resident #32 and Resident #88 to receive oxygen. The facility failed to replace Resident #32's oxygen humidifier bottle when empty. The facility failed to replace Resident #88's nasal cannula when it was discolored and it was not dated. This deficient practice could affect resident who received oxygen therapy continuously placed him at-risk for respiratory infection, and ineffective treatment. Findings included: 1. Record review of Resident #32's Face sheet, dated 07/25/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #32's quarterly MDS assessment, dated 05/02/24, reflected her had a BIMS score of 02 which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for 4 (Resident #30, #75, #127 and #136) of 6 residents reviewed for dialysis. 1.The facility failed to maintain dialysis communication sheets for Residents #30, #75, #88, #127, and #136. This failure could place residents at risk of inadequate post dialysis care. Findings included: 1.Record review of Resident #30's undated admission Record reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included kidney failure requiring dialysis, dementia, and diabetes. Record review of Resident #30's quarterly MDS, dated [DATE], reflected a BIMS score of 9, indicating she was mildly cognitively impaired. Her Special Treatments indicated she required dialysis. Record review of Resident #30's care plan, date 5/17/24, reflected she received hemodialysis every Monday, Wednesday,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 2 (Residents #35 and #246) of 6 residents reviewed for pharmaceutical services. 1.LVN F failed to follow physician orders for administering Exelon transdermal patch to Residents #35. 2.LVN K failed to follow the physician orders for administering medication to Resident # 246s, when he administered Nafcillin Sodium Injection Solution (Nafcillin Sodium) (antibiotic) 12g/1000mls intravenous to Resident #246. These failures could put residents at risk of not receiving their medications as ordered. Findings included: Review of Resident #35 's quarterly MDS assessment, dated 07/15/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included Parkinson's(is a progressive disorder that affects the nervous system and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater on 2 errors of 27 opportunities for errors leading to 7.41% medication error rates for two (LVN F and LVN K) of four staff observed for medication pass. 1. The facility failed to ensure LVN F administered medications as ordered to Resident #35 by administering Exelon patch (a treatment for Parkinson and dementia) without removing the old patch on 7/23/24. 2. The facility failed to ensure LVN K properly administered medications as ordered to Resident #246 when administering Nafcillin 12gm/1000mls every 24 hours, LVN K did not ensure the bag was completely empty (discarded 400mls) before administered a new bag. These failures resulted in a 7.41% medication error rate and could put residents at risk who received medications for not receiving the correct dose of medication and getting intended therapy. Findings include: 1.Review of Resident #35 's quarterly MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain clinical records that were complete and accurate for five (Resident #30, #18, #88, #75, and #127) of six residents reviewed for clinical records. 1. The facility failed to obtain a physician order for Dialysis for Resident #30. 2. The facility failed to obtain a physician order for Dialysis for Resident #18. 3. The facility failed to obtain a complete physician order for Dialysis for Resident #127. 4. The facility failed to obtain a physician order for Dialysis for Resident #88. 5. The facility failed to obtain a physician order for Dialysis for Resident #75. This failure could place residents at risk for incomplete and inaccurately documented medical record that included their progress treatment, services, and interventions. Findings include: 1. Record review of Resident #30's undated admission Record reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included kidney failure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Residents #25, #71, #103 and #244) of 10 residents reviewed for infection control. 1. The facility failed to provide signage and PPE for Resident #71, who was on Enhanced Barrier Precautions (EBP). 2. LVN L failed to don appropriate PPE (gowns) before providing bolus feeding to Resident #103, who was on Enhanced Barrier Precautions. 3. LVN K failed to perform hand hygiene, disinfect the blood pressure cuff between residents while monitoring blood pressure to Resident #25,and #244 and while administering medication to Residnet#25. This failure could place residents at risk of contracting an infection from residents on Enhanced Barrier Precautions. and cross contamination, which could result in infections or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews the facility failed to ensure resident rooms were equipped to assure full visual privacy for each resident for 6 (Rooms 321. 322, 323, 324, 325, 327) of 6 rooms reviewed for full visual privacy. The facility failed to ensure privacy curtains in rooms Rooms 321. 322, 323, 324, 325, 327 could provide full visual privacy for both residents. This failure could cause a decrease in feelings of self-worth by being exposed during cares. Findings included: Record review of Resident #71's undated admission Record reflected he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included heart attack, urinary tract infection, heart failure, and high blood pressure. Record review of Resident #71's quarterly MDS assessment, dated 6/28/24, reflected a BIMS score of 8, indicating moderate cognitive impairment. His Functional Status assessment indicated he required partial assistance with all of his ADLs. His Bladder and Bowel Assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and interviews the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 4 (Residents # 93, #236, #243, and #435) of 8 residents reviewed for pest control. The facility failed to ensure Residents # 93, #236, #243, and #435 were free from risk of mosquito bites. This failure could place residents at risk of exposure to viruses spread by mosquitos. Findings included: Phone interview/ Observation on 7/22/24 at 12:10 PM Resident #435 stated on 7/7/24 she suffered multiple mosquito bites to her hands, arms, neck and face during the night while sleeping. She notified the staff on the morning of 7/8/24 and they applied ointment to her bites. Observation of photos submitted by Resident #435 to the surveyor which appeared to show 11 bites to her right hand, and two blisters; 8 bites to her right forearm; 15 bites to her left forearm; 2 bites to her right neck; and 6 bites to her right face. Interview and observation on 7/23/24 at 3:00 PM Resident # 236 stated he was bitten several times by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #89) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #89 was given a SNFABN (SNFABN document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services. Findings included: Record review of Resident #89's face sheet dated 07/25/2024, indicated a [AGE] year-old male, originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included displaced fracture of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 5 residents (Resident #9) reviewed for MDS assessment accuracy. The facility inaccurately coded Resident # 9's quarterly MDS assessment dated [DATE] for dialysis treatment when she was not receiving dialysis treatment. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Review of Resident #9's face sheet dated [DATE] indicated Resident #9 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #9 had a diagnosis of chronic kidney disease, stage 4 (severe loss of kidney function), and kidney transplant status (surgery to place a healthy kidney from a living or deceased donor into a person whose kidneys no longer function properly). Review of Resident #9's admission MDS dated [DATE] revealed Resident # 9 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS Assessment for Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #136 and Resident #103) of 7 residents reviewed for comprehensive care plans. The facility failed to update Resident #136's care plan to address dialysis. The facility failed to update Resident #103's care plan to address fecal impaction (constipation). This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life. Findings included: 1. Record review of Resident #136's Face sheet, dated 07/25/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections based on the resident's comprehensive assessment for 1 of 3 residents (Residents #71) reviewed for urine incontinence/catheters. The facility failed to ensure Resident #71' catheter urine collection bag was kept off the floor and had a privacy cover. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Review of Resident #71's admission Record dated 07/24/24 reflected Resident was a [AGE] year-old male, admitted to the facility on [DATE]. Review of Resident #71's MDS assessment, dated 06/28/24, reflected the resident had severe cognitive impairment with a BIMS score was 8, and he required partial/moderate assistance with toileting. Resident #71's diagnoses included Urinary Tract Infections, Hypertension (high blood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for one (Resident #103) of three residents reviewed for gastrostomy tubes. LVN L failed to flush Resident #103's g-tube with 30ml of water before and after medication administration and provide 100 ml before and after his bolus feeding (feeding method using a syringe to deliver formula through feeding tube) as ordered by the physician. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care. Findings included: Record review of Resident #103's Face sheet, dated 07/25/24, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #103's quarterly MDS assessment, dated 07/15/24, reflected his diagnoses included unspecified sequelae of cerebral infarction (stroke),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to conduct and document a facility wide assessment that addressed the care required by the resident population and the facility's resources for 1 of 1 facility assessment, in that: -The facility assessment inaccurately reflected that there were no dialysis patients in the facility. -The facility assessment did not include contracts, memorandums of understanding, or other agreements with third parties to provide services for dialysis. This deficient practice could place residents at-risk for inadequate care or treatments due to an inaccurate assessment. The findings included: Record Review of Resident #18's face sheet, dated 08/01/24, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE]. His diagnoses included end stage renal disease, dependance on renal dialysis, and unspecified dementia (memory loss). Record Review of Resident #18's annual MDS Assessment, dated 05/16/24, reflected that the resident had a BIMS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure agreements pertaining to services furnished by outside resources specified in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility for 1 of 1 dialysis facilities reviewed for dialysis services. -The facility did not have a written agreement with the dialysis center for Resident #18. This failure could place residents requiring dialysis at risk for failure to receive dialysis services due to lack of coordination of care with a dialysis center and therefore potential physical harm and psychosocial harm. Findings include: Record Review of Resident #18's face sheet, dated 08/01/24, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE]. His diagnoses included end stage renal disease, dependance on renal dialysis, and unspecified dementia (memory loss). Record Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 2 residents (Residents #109 and #119) reviewed for hospice services. The facility failed: 1. To obtain Resident #119's physician's order for hospice services. 2. To obtain Resident #109's physician's order to discharge from hospice services. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record Review of Resident #119's face sheet, dated 07/25/24, reflected the resident was a [AGE]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to ensure residents have the right to receive visitors of his or her choosing on day and time of his or her choosing for 1 of 2 (Resident #2) residents reviewed for resident rights. The facility failed to ensure Resident #2 had the right to receive visits from Family Member #1 since 11/27/23 inside the facility. This failure placed residents at risk of isolation, decreased emotional wellbeing and diminished quality of life. Findings included: Record review of Resident #2's face sheet, dated 06/04/24 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), vascular dementia (decline in cognitive function due to reduced blood flow to the brain) hypertension (high blood pressure), chronic kidney disease and (long standing kidney disease that results in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent the release of resident-identifiable information to the public, and also failed to maintain medical records that were complete and accurate for 1 Resident #1) of 4 residents reviewed for clinical records. 1. On 11/23/23 LVN A discussed Resident #1's medical conditions with a family member not authorized to receive the information. 2. On 11/23/23 LVN A failed to accurately document Resident #1's disposition after she left AMA, as well as events leading up to Resident #1 leaving AMA. These failures could place residents at risk of incorrect or incomplete documentation of their conditions as well as the release of personal information that could be used for illicit purposes. Findings included: Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of sternum (breast bone) fracture, history of multiple falls, heart attack, heart disease, and diabetes.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for contaminated sharps disposal bins, attached to 1 (LVN A) of 2 nurse medication carts and 1 of 1 Wound Care Carts, on Station Two Wing, reviewed for hazards in that: LVN A failed to ensure contaminated sharps in the sharps bin attached to the Nurse Medication Cart she was responsible for, on Station Two Wing, were below the full line. LVN B failed to ensure contaminated sharps in the sharps bin attached to the Wound Care Cart, on Station Two Wing, were below the full line. These failures placed residents at risk of being exposed to contaminated sharps and possible blood borne pathogens. Findings included: An observation on 05/10/24 at 12:59 PM revealed the treatment cart parked against the wall, in a common area by Station 2 Nurses Station. The lid on the plastic insert inside the sharps bin attached to the cart was half open. Sharps were filled to the top of the bin approximately two inches past the marked fill line.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biological's were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two of four (Medication Cart #1 and Medication Cart #2) medication carts reviewed for pharmacy services. The facility failed to ensure Medication Cart #1 was locked when unattended, and medication cart #2's keys were secured by assigned RN. Both carts contained controlled medication lock box. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings include: In an observation and interview on 02/16/24 at 2:00 PM revealed Medication Cart #1 was in the 200 halls in front of the nursing station facing out ( the back of the med cart was pushed up to the nursing station counter, and unlocked medication storage was facing the walkway where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for the facility's only kitchen. The facility did not maintain an effective pest control program to ensure the facility was free from rodents in the kitchen and the kitchen's dry storage room. This failure could place residents at risk for an unsanitary environment and a decreased quality of life. Findings included: A record review of the facility's grievances, dated 09/12/23, reflected: .there were rats in the kitchen. The grievance report reflected the facility's resolution of concern, dated 09/13/23, revealed On 9/13/2023, there was a rodent observed scurrying by the directors office, she immediately notified main department and sticky traps were placed. The rodent was captured and disposed of the next morning. The kitchen was thoroughly cleaned and power washed with no other evidence of pests noted. [Pest Control Company] will increase their monitoring and additional sticky traps were placed with no other captures…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to submit a discharge MDS assessment and transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State for four (Residents #2, #18, #129, and #140) of four residents reviewed for timely discharge MDS submission. The facility failed to successfully submit discharge MDS assessments for Residents #2, #18, #129, and #140 when they discharged from the facility. This failure could prevent communication about a resident's status from being transmitted to CMS and could interfere with residents receiving needed services after discharge. Findings: Review of Resident #2's face sheet, dated 06/07/23, reflected she was a [AGE] year-old woman, admitted on [DATE], with diagnoses of lupus and dementia. Review of Resident #2's Discharge summary, dated [DATE], reflected she was discharged to her home. Review of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to prepare puree and regular food by methods that conserve nutritive value, flavor, texture and appearance that is palatable, attractive, and at a safe and appetizing temperature for 8 of 11 residents (Resident #36, #46, #10, #125, #91, #121, #73, and a confidential resident) reviewed for regular diets. The facility failed to ensure that regular diets served were prepared by methods that conserve nutritive value, flavor, texture, and appearance. This could place residents on regular diets at risk for a decrease in quality of life and possible weight loss. Findings included: Interview on 06/06/2023 at 9:56 AM, Resident #10 stated she does not like the type of food they serve. Interview on 06/06/2023 at 10:03 AM, Resident # 125 stated the food is garbage, has minifridge with own food, and sometimes will choose alternative from menu but generally the food served was not his taste. Interview on 06/06/2023 at 10:23 AM, Resident #91 stated he would like to have more variety in his meals. He stated he does not look…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 11 residents (Resident #121 and Resident #36) reviewed for reasonable accommodation of needs. 1. The facility staff did not answer Resident #121's call light timely. 2. The facility staff did not place Resident #36's call light within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: 1. Review of Resident #121's face sheet, dated 06/08/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cervical disc degeneration (neck pain with difficulty moving arms and legs), muscle wasting with atrophy, and type 2 diabetes. Review of Resident #121s Annual MDS,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.